Don't think of privatization

Let's do a little thought experiment today.

Close your eyes. Imagine a privatized healthcare consortium as vividly as you can. It is clear! Is it? There are private owners. Or seems to be some officials geting dividends?

Now, I want you to NOT think about privatization. Think of anything else but privatisation. Try it for a few minutes.

What are you thinking of? How many times did the privatization issue cross your mind? Quite a few times, right?

Now, close your eyes again and try to think about what you did for today? Who you met? Where you went? Anything interesting happened when you were traveling? What did you eat for breakfast/lunch? Try it for a few minutes.

How many times did you think of privatization? None? Maybe once or twice especially since I asked this question?

This is an exercise that shows that suppressing your thoughts in your mind doesn't really work. When we try not to think about something and try to suppress it, our minds keep going back to the same thoughts. This is a well known experiment from Wegner et al. (Wegner, D. M., Schneider, D. J., Carter, S. R., & White, T. L. (1987). Paradoxical effects of thoughts suppression. Journal of Personality and Social Psychology, 53, 5–13). As you know, I could also refer to Lakoff mental frames and its: Don't think of an elephant for different evolutive and modern cognitive perspective, but I've done it before.
If you combine deception -about the concept of privatization- and the difficulty of suppressing your thoughts, you'll get the current health policy mess. Distraction is a strategic move that has alleged political profits. For sure, the whole population only receive the losses from such strategy. We have been installed in this paradigm for many years: the privatization devil is here and there, although there is no shareholder getting any dividend. Fortunately, the world stands beyond spaguetti western films. Ownership has impact on efficiency but depends on the context, sometimes public incentives prevail over private ones, and sometimes is the opposite.
If all these sounds weird to you, have a look at our last Parliament resolution and you'll find the astonishing agreement of all parties against the current ruling party on one issue that doesn't exists: a public consortium privatised!!!. If it is public, as it is, can't be private if the owner is the government, as it is. Disappointing, shameful.
I'm really sad that in my country public representatives play with fire in such a way. I just want to say today, that I'm available for those deputies interested in a free private lecture on organizational economics, on what ownership is and what it means for efficiency. Just give me a call or send me an email.

A relaxing cup of café con leche

The size of the private hospital market

There are two sources to find the size of the private hospital market: EESRI and DBK a consulting firm. The number of beds is close to 30.000 in both sources, the size of income is 6.185 m€ for 2013 according to DBK, and additional 1% compared to the previous year. Private hospitals receive 66% of their income from insurance companies. In 2013 it grew 3,4%, while health insurance premiums rose 2,8%. Public funding of private hospitals is decreasing, -4% and private out-of -pocket as well -3,2%. Insurance companies are increasingly funding private hospitals beyond its growth in premiums. Such figures show a clear pattern that is being replicated in the last years. I wrote a post on such trend about three years ago. What I said there, is already confirmed today.

PS. For those that consider privatization as public funding of services in private organizations, and for those that support that the size of privatization is growing, these data testify just the opposite. Therefore, where is the underpinning of the argument?

PS. In my opinion, as I said in this post some time ago, it is not privatization, it is commercialism.

Commercialism in health and medicine

Buying Health: The Costs of Commercialism and an Alternative Philosophy

There are only three topics of health policy in the newspapers (unfortunately): waiting lists, copayments and privatization. As soon as one topic drops from the agenda, the informational cascade starts with the following one. The last one, privatization is still a concept in need of definition and measurement. I already covered this issue last year and I don't want to repeat it.
Today I would like to insist that beyond a new framing of the concept, maybe we have to change the scope and the term. The right term could be commercialism. We have to understand better how and when commercialism is undermining professionalism.
Jerome Kassirer wrote an excellent piece (US oriented) in Cambridge Quarterly of Healthcare Ethics some years ago that it is still a reference for today. His words:

Professionalism is fundamentally a pact with society. In recognition of certain behaviors and attributes, society confers professional status on us. These privileges are not bestowed, but are earned, and they must be renewed repeatedly for the status to be preserved. Professional behaviors include technical competence that is valued and that adds value, a commitment to self-improvement, a commitment to selfmonitoring and self regulation, and a commitment to use the unique knowledge and competence for the best interests of our patients. This last requirement should include a commitment to resolve conflicts of interest in our patients’ favor.

Is money trumping professionalism? Certainly the pharmaceutical money tsunami is having major adverse effects. It tends to distract faculty into emphasizing profitable research and to neglect their teaching duties. It replaces openness with secrecy, it privatizes knowledge, and it replaces part of the social commons by commercializing discovery. In many instances, it downplays knowledge as a social good. It has also created a culture within which the design of studies is sometimes jiggered to create positive results, in which unfavorable results are sometimes buried, where communication of results is sometimes hindered for commercial reasons, and where bias in publications and educational materials has gone completely unchecked

Maybe there are excessive generalizations, but take it as a general statement to be confirmed by facts and data.
Churchill and Churchill go beyond the usual scope. Their recent article abstract says:

This paper argues that commercial forces have steadily encroached into our understanding of medicine and health in modern industrial societies. The impact on the delivery of personal medical services and on common ideas about food and nutrition is profound and largely deleterious to public health. A key component of commercialization is reductionism of medical services, health products and nutritional components into small, marketable units. This reductive force makes both medical services and nutritional components more costly and is corrosive to more holistic concepts of health. We compare commercial and holistic approaches to nutrition in detail and offer an alternative philosophy. Adopting this alternative will require sound public policies that rely less on marketing as a distribution system and that enfranchise individuals to be reflective on their use of medical services, their food and nutrition choices, and their larger health needs

I deeply agree with such perspective.

Falsehood as ingredient of populist health policy

On Rumors: How Falsehoods Spread, Why We Believe Them, and What Can Be Done

Today I would like to suggest you to read Barack Obama in his farewell speech. It's an inspiring piece to understand US and democracies in general. Inequality, racism and polarization are the three key isues to tackle.
He said:

For too many of us, it’s become safer to retreat into our own bubbles, whether in our neighborhoods or college campuses or places of worship or our social media feeds, surrounded by people who look like us and share the same political outlook and never challenge our assumptions. The rise of naked partisanship, increasing economic and regional stratification, the splintering of our media into a channel for every taste – all this makes this great sorting seem natural, even inevitable. And increasingly, we become so secure in our bubbles that we accept only information, whether true or not, that fits our opinions, instead of basing our opinions on the evidence that’s out there.

This trend represents a third threat to our democracy. Politics is a battle of ideas; in the course of a healthy debate, we’ll prioritize different goals, and the different means of reaching them. But without some common baseline of facts; without a willingness to admit new information, and concede that your opponent is making a fair point, and that science and reason matter, we’ll keep talking past each other, making common ground and compromise impossible.

Without a common baseline of facts there is no possibility to talk to your political opponent. Nowadays, fake news like health privatization are continuously spreading without any foundation. Our health minister speaks incredibly about that in our Parliament. Such obsession has driven to submit a new unnecessary law on health contracting.We are now in an obsession focused policy era.
To understand this phenomena, Sunstein wrote a book in 2008, before thee term post-truth era, that explains the basics and what to do.
Cass Sunstein says in the book:

Rumors are nearly as old as human history, but with the rise of the Internet, they have become ubiquitous. In fact we are now awash in them. False rumors are especially troublesome; they impose real damage on individuals and institutions, and they often resist correction. They can threaten careers, relationships, policies, public officials, democracy, and sometimes even peace itself. Many of the most pervasive rumors involve governments—what officials are planning and why.

This small book has two goals. The first is to answer these questions: Why do ordinary human beings accept rumors, even false, destructive, and bizarre ones? Why do some groups, and even nations, accept rumors that other groups and nations deem preposterous? The second is to answer this question: What can we do to protect ourselves against the harmful effects of false rumors? As we shall see, part of the answer lies in recognizing that a “chilling effect” on those who would spread destructive falsehoods can be a truly excellent idea, especially if those falsehoods amount to libel.

Sensible people believe rumors, whether or not they are true. On the Internet, self-interested, malicious, and altruistic propagators find it increasingly easy to spread rumors about prominent people and institutions. Such rumors cast doubt on their target’s honesty, decency, fairness, patriotism, and sometimes even sanity; often they portray public figures as fundamentally confused or corrupt. Those who are not in the public sphere are similarly vulnerable.

Rumor transmission frequently occurs as a result of cascade effects and group polarization. Indeed, rumors spread as a textbook example of an informational cascade: imperfectly or entirely uninformed people accept a rumor that they hear from others, and as more and more people accept that rumor, the informational signal becomes very strong, and it is hard for the rest of us to resist it, even if it is false.

Group polarization also plays a large role, as people strengthen their commitment to a rumor simply because of discussions with like-minded others.

 If you want people to move away from their prior convictions, and to correct a false rumor, it is best to present them not with the opinions of their usual adversaries, whom they can dismiss, but instead with the views of people with whom they closely identify

The signal of the rumor may be so strong that though reality is absolutely different, and everybody is finally conceding it the value of truth. This is sadly what has happened to health privatization debate.

Capable governments as a precondition

 The Right Privatization. Why Private Firms in Public Initiatives Need Capable Governments

Beware of the framing effect

Inevitably the debates over health reform are rooted in what we currently observe. And our perception is subject to be selected according to our preferences. Decision making under uncertainty has explained how individuals depart from rationality towards multiple biases and this is present everyday in health policy debates.
Currently, the demonstrations against what is called privatization of health services have achieved a difficult tipping point. Both parts, those that are in favour and those that are against are subject to framing effects. In simplest terms, a frame is a model, or lens, for understanding, interpreting, and solving a problem. Politicians have a number of frames that they use to judge people, simplify problems, and make decisions. While framing a concern represents the initial step toward a successful resolution, it is also the first place a decision can go wrong. Because most problems can be framed, or looked at, in more than one way, the lens politicians employ to define an issue can significantly influence how they respond.
And this is exactly what is happening. The frame under the current proposals is that "private management is cheaper". We are not discussing efficiency, lens are focusing on implicitly saving money. Unfortunately this frame should be confronted with the reality. Is it really cheaper? Is being cheaper enough?. Data is scarce and evidence is pending to be provided.
Therefore the recommendation would be: frame the problem from a larger number of reference points and perspectives. A variety of frames allows the decision maker to evaluate the goodness of fit with the specific context. And this is what nobody wants to talk about, about the context. Different ownership alternatives may contribute to efficiency in different ways according to context and the behaviour of the regulator.

PS. On framing bias in medicine and how to tackle it.

La reforma responsable dels serveis públics

PUBLIC SERVICES FOR ONTARIANS: A PATH TO SUSTAINABILITY AND EXCELLENCE
A Ontario van crear una comissió per tal que oferís recomanacions per un pressupost equilibrat del sector públic a 5 anys vista. El mandat era:

There are five parts to our mandate:
1. Advise on how to balance the budget earlier than 2017–18.
Given the deterioration in the economic outlook since the 2011 Budget, we believe an earlier target for balance is neither practical nor desirable.
2. Once the budget is balanced, ensure a sustainable fiscal environment.
Our proposals aim to keep the budget roughly in balance after 2017–18. We attach great importance to this goal.
3. Ensure that the government is getting value for money in all its activities.
We see this as a requirement to recommend ways of ensuring that all programs and services achieve the best possible outcomes within available resources.
4. Do not recommend privatization of health care or education.
We interpret this to mean that health care must be kept within the public payer model. We do not interpret it as denying opportunities for private-sector delivery of services, if that is more efficient.
5. Do not recommend tax increases.
Although our mandate precludes us from recommending higher taxes, we do recommend ways to raise more revenue without adjusting tax rates.
Government ministries and agencies should always strive for efficiency gains, not only when driven by overall budget restraint or in response to problems unearthed by the Auditor General or exposed by a spending scandal.

 Tasca complexa per a una comissió. Aquí més d'un no acceptaria de participar-hi amb aquestes restriccions. Ara que ja han publicat el treball, paga la pena llegir-lo, salut és al cap 5.
Qué lluny som de la reforma responsable que fan els canadencs d'Ontario! I qué diferent podria ser tot plegat si adoptéssim una visió semblant!